Returning to Activity in the Postpartum Phase: Podcast Episode #276

Many of our listeners want to know when it is safe to return to activity in the postpartum phase, so Kristin sat down with Dr. Carrie J. Pagliano to discuss this topic and so much more.  Carrie is the owner of Carrie Pagliano Physical Therapy.  

Hello, hello!  This is Kristin Revere with Ask the Doulas, and I am thrilled to chat with Dr. Carrie J. Pagliano.  She has been a dynamic leader in the areas of women’s pelvic health for over 25 years.  Dr. Pagliano received her master’s in physical therapy from the University of the Sciences in Philadelphia in 1999, and doctor of physical therapy from University of St. Augustine for Health Sciences in 2007.  Dr. Pagliano is a double board certified clinical specialist in orthopedics and women’s health.

Welcome, Dr. Pagliano!

Thank you!  I feel old when you say 25 years.

That is so impressive, and so much has changed in your industry over the years.

That’s an understatement, for sure.

I would love to hear a bit more about how you decided to focus on pelvic floor physical therapy, of all of the different specialties within physical therapy.

So 25 years ago, this wasn’t the plan.  That’s the short summary.  I graduated in 1999, and I thought I wanted to go into neuro physical therapy, so working with the stereotypical patients with strokes, spinal cord injuries, those sorts of things.  I mean, we all want to help people when we go into this field.  And the year that I graduated, there were huge changes in managed care, and out of the 60 people that I graduated with, only 6 of us had jobs upon graduation.  So things had to switch around a little bit.

I stayed in Philadelphia for a couple of months doing home care and then went back to Western New York to work in a small, rural hospital, and thought I wanted to go to med school, because PT wasn’t really doing it for me at that point and kind of went through all the processes to finish up my prerequisites, and then at the first chance, took a job in Washington, D.C. to get out of being back home and a little bit more of a metropolitan area.  I was hired to work in, at the time, what wasn’t termed pelvic health.  It was termed women’s health because we weren’t really doing anything for men.  There really wasn’t trans therapy and things like that.  And so I learned how to do that.  It wasn’t anything that – basically, pregnancy, postpartum.  You were going to get Kegels.  And if you had pelvic pain, you were going to get some sort of biofeedback.  So there really wasn’t a lot of depth to what we did at the time.

So I was doing orthopedics parallel to that, and then several years later, I started to sort of mash them up and realized, there’s a lot of things that we’re missing, and treating just the pelvic floor in isolation really is missing a huge component of understanding how the body works.  Ever since that mash-up, I’ve kind of blended those two things, which was really unique at the time.  It’s very normal now, which is cool.  I thought that I had the birth thing kind of figured out, and then my oldest son decided to teach me a lesson, that I did not have everything figured out.

Yes, they love to teach us lessons!

They do.  And then after my daughter, I navigated some issues with diastasis, which is abdominal separation.  I had some issues with incontinence, pelvic organ prolapse.  Kind of all the things that I thought that I could, A, either prevent or B, treat completely.  At the time – my kids are 11 and 13 now – we didn’t have the data that we have now.  We didn’t have ways to get back to running.  We didn’t have return to run readiness screenings things, all sorts of things.  The option was either, be active and suffer, or don’t be active.  And I wasn’t going to choose the not being active part.  Personally, this was me going further into pelvic health and working with female athletes and things like that.  I really was driven by the lack of support and knowledge around when I was looking.

So my job since then has been to be that resource that I did not have.  So no, that was not the plan, but what’s super cool is the research is evolving constantly.  There’s some really amazing women working in research in a lot of these different areas.  Now we’re jumping ahead and looking into perimenopause, and there’s so many parallels between perimenopause and early postpartum, so now shifting back and looking at all those different phases differently.  There’s so many more expectations for what women can do in pregnancy now as far as running, weight lifting, all these things that just weren’t expectations or things that we even dreamed of back when I was pregnant and having my babies.  That’s the really cool part about the job that I have is it constantly changes, and that’s why I stay in it.

And as an athlete yourself, you can relate to your patients who want to return to their passion, whether it’s running or biking or tennis, and not have discomfort and leaking.

Exactly.  It’s one thing to know it by a book.  It’s another thing to know it having lived it.

You can be relatable.  I find that as a doula.  Having gone through preeclampsia, breastfeeding struggles, and all of the things, it made me a more empathetic and, in my opinion, a better doula.

100%.

So what are your tips for our listeners who are either pre-conception or just had their baby that want to return to activity, and what are your best resources if they can’t work with you directly?

I think the first thing we have to address, the elephant in the room, is social media, because that’s where a lot of people turn to get their information, and it’s wonderful because there’s a lot of information.  It’s also horrible because there’s a lot of information.  And vetting your resources is incredibly important in understanding that in the pregnancy and postpartum space, people can take a weekend course and have a kid and then all of a sudden call themselves experts.

Right, a coach of some sort, yes.

Yes.  And just because you’re an N of one, just because you had a kid, doesn’t mean you know all the things that can go on in this time period and in this season.  That’s become a very common thing is people sharing their experience and then implying that they’re an expert because they’re sharing their experience.  So when you are considering becoming a parent and being pregnant and navigating this and building your information team, whether that’s virtual or local to you, I think it’s important to vet your resources.  And the nice thing that I can say now is it’s not super hard to find resources that are niche.  So, for example, if you’re a runner, it’s not that hard now to find running-informed pregnancy, postpartum, certified trainers, or running informed pelvic floor pregnancy postpartum physical therapists.  Or if you’re into CrossFit or tennis or things like that.  So there’s a lot more good quality information.  You just might need to dig a little bit.

The other thing to know, too, is that the information that’s out there is evolving.  So you’ll see general recommendations, but you might have some nuances and changes depending on what’s going on with you medically, what’s going on with your baby, what resources you have as far as your local birthing team, that sort of thing.  So what I always tell moms is the more – and again, I live in the metro D.C. area, and we have a lot of older moms, myself included – and the more rigid you are about this process, the more it will come bite you in the bottom.

Agreed, as a doula.

This is from someone who laminated their first birth plan that their son never read.  So I feel like I can say that.  The more flexible you are – and again, this is also for people who really want to have a vaginal delivery and things like that.  We can have all the conversations about what we can do to prepare and be active, but let’s also be ready for these other things and have some basic understanding because as you well know, a lot of times if you plan for one thing and the other thing happens, it can be devastating.  And so what we’re trying to do from a physical therapy standpoint is look at past history, injury history, anything like that, that might lead us to believe that we might need to work on hip mobility or pelvic floor down training or things like that.

One of the things that I think is a really important tip is – and still providers do this.  They’re like, oh, do your Kegels.  Actually, the pelvic floor’s job is to relax and get out of the way and let the uterus and the baby do their job to kind of work through the delivery.  And so quite often we have athletes that may have higher tone or higher activity in the pelvic floor that we really need to work on relaxing that pelvic floor, working on hip opening positions, and that’s where we have a great partnership with doulas about what positions might be most beneficial to help that pelvic floor relax.  So that’s one of the first things that we look at.  Can we do things ahead of time?  The first time you deliver, you’re an N of one to yourself and you’re an N of one to your provider.  So I feel like that’s the first part.

The second tip I have is to establish your postpartum team in pregnancy.  So if you have the ability to connect with a local pelvic floor PT in person, that’s great.  Telehealth has been amazing for pregnancy and postpartum care.  I actually am licenses in multiple states so that I can do that.  I also do virtual consults and collaborate with local resources.  Again, I grew up in a rural area.  The closest major hospital was 70 miles away.  Your care shouldn’t be dependent on your ZIP code.  And so making sure that you have a team set up so it’s all planned and ready to go, and then be able to have follow up care within two to three weeks of that delivery, regardless of whether it’s a vaginal delivery or Cesarean section.  Because you don’t want to be doing nothing that first six weeks.  For some people, they want to get going sooner, and typically, those scenarios are when baby is eating well, baby is sleeping well, everybody’s happy.  That’s when moms ask to be more active sooner.  We say definitely work on walking, working on reconnection, and then by the time we get to that six week period, we’re at 75% soft tissue healing.  Then, okay, let’s look at where the deficits are.  Where do we need to focus from a strength perspective?  What’s the timeline on getting back to a walk or run program, if we’re talking about that?  Can we do empty barbell as far as weight lifting goes?  I think there’s a lot of things that we can establish in those early weeks.  And also guide moms to get maybe a postpartum doula or a breastfeeding consultant or sleep consultant or something just to help make that a little bit easier, those first few weeks.  So those are the first big tips for moms thinking about this time and space.

Excellent tips.  I couldn’t agree more.  As far as when to hire a pelvic floor physical therapist, you talked about planning ahead during pregnancy, but I think there’s this misconception that you wait to see a pelvic floor physical therapist until after you’ve delivered.  But you can actually see one in pregnancy, in addition to a physical therapist?

You can come see us anytime!  So in all 50 states here in the US, there is some degree of what we call direct access.  So by law, you can see a physical therapist without a physician’s order at least for that initial visit.  Now, everybody’s insurance requirements are a little bit different, and that’s a separate conversation about insurance companies dictating care, but from a legal standpoint, in all 50 states, you can directly access a PT.  That being said, a lot of times I’ll have moms come in during pregnancy once we know for sure we’re in the second trimester, the pregnancy is viable, just to get a sense of what questions they have, what support they might need, if they’re having musculoskeletal issues, meaning like if you’re having pubic bone pain or hip pain or sacroiliac pain.  A lot of doctors are like, this is just how it is, and there’s a lot of things that we can do to keep you as active as possible and also provide any modifications that you might need for exercise that you’re sticking to.  You don’t have to just go do prenatal.  And this is a big change.  You can keep up with a lot of stuff that you might have already been doing.  A PT is going to be really helpful with that.  And then typically, we will set that postpartum visit while you’re pregnant so it’s already set.

The other thing to remember from a logistics perspective, there’s so many more pelvic floor PTs in this country than there were when I started.  A lot of these major health systems that have multiple therapists and are participating providers with insurance will have six month waitlists.  So you’ve got to plan early because if you’re not calling until six weeks and you’ve got an issue and you’re not going to be seen for six months, that’s no good either.  Unfortunately, it’s one of those things.  I think what we’re running into now is very similar to what I hear is happening in the UK where there is the public system, but again, it’s going to be very long to wait, and so there’s a lot of private providers that you can get to see a little bit sooner and still get great care.  A lot of times, actually, a lot of us have left the major hospital systems because we don’t want the insurance companies to drive our decision making.

I can understand that.  It’s very complex.  We even have some pelvic floor physical therapists in our area that do home visits.  They’re not in a big firm.

It’s been a big boom, I would say, the last five years or so.  And a lot of us – very similar to doulas – were working in other areas in physical therapy and switched over into pregnancy and postpartum because they had their own kids.  They’re also looking for a more flexible schedule, so concierge or coming to you works great.  There’s a huge boom right now in telehealth, which I personally love, one, because we can do an easy switch back and forth.  So if I have a client, for example, whose kid is sick, we don’t need to cancel the appointment.  She can still be at home.  She can still care for her sick child.  We just switch the appointment over to telehealth and mom can still get her care and not put herself on the back burner.

So wonderful!

It is!  Again, we need to prioritize the caregiver and again, also those women that may live in locations – I talked to a client yesterday.  Her closest physical therapist was five hours away.  And unfortunately, she made the trip, got there, and it wasn’t a great scenario.  The lady was talking about moons, stars, oh, this is just how it is.  I’m really not kidding.  And I was like, no.  Poor thing, ten hours round trip and didn’t get anything out of it.  So again, your ZIP code shouldn’t necessarily dictate your access to healthcare.

I love that there are so many more options now.  Thank you for sharing all of that, Carrie!  As far as other tips for our listeners, is there anything else that you would like to share about getting back to whatever activity our listeners are passionate about?

I think, again, it’s the danger of the internet.  When we have a symptom we did not expect, even if everything went right in pregnancy and then all of a sudden you’re having leakage or pelvic pressure and you’re googling pelvic organ prolapse or doomscrolling diastasis recti, it’s important to get in front of somebody that this is what we live, eat, and breathe all day long.  It can get real ugly real quick, especially, I think, pelvic organ prolapse, the idea of an organ not sitting where it’s supposed to be, you feeling heaviness and pressure, maybe even seeing something down there – it can be really mentally detrimental, and it can make you really scared to be active.  And the fact of the matter is there are so many more options to get active and symptom-free without even consulting a surgeon, and people just don’t realize it.  And so getting in front of somebody that they’re used to navigating these complex issues in active women is so important because if you wait and you think, oh, well, it will just get better if I just rest or just kind of ignore it, and then you want to come back later on – which I see a lot of now, women that didn’t get things addressed ten years ago.  They’re now active in perimenopause, but they still have the same issues that they did in early postpartum.  We need to support getting our moms back to activity early.  It’s not stuff that just goes away on its own.  You want to treat it as a rehab of a major injury that deserves attention, deserves medical expertise, deserves somebody to legitimately listen to your story, listen to your concerns, and provide you with a really well evidence-informed process back to activity.  We gaslight ourselves enough; let’s not make this be another one of those situations.

It’s such a good point to talk about ten years later, still having discomfort or pain or leakage.  I mean, is there evidence that if you treat yourself early in the postnatal phase, that you can avoid issues later in life, as an older woman, like to avoid adult diapers, for example, with the leakage?

I don’t think that evidence is there per se, but if you walk it back – so, for example, those of us who this has been our day job and we’ve had to navigate it ourselves, diving into perimenopause when all of a sudden you have a big drop in estrogen and you’ve got some shifts and changes – like, I’m good, but I have plenty of clients who are coming now.  Maybe they didn’t know about pelvic floor PT 12, 13 years ago.  Maybe they didn’t do anything and they said, you know, just a little leakage, it’s fine.  But they get to that time period where, again, estrogen’s dropping.  They don’t have the strength because they haven’t stayed as active.  There’s definite implications on just overall health and we want to be active.  So I think that data will be established.  Don’t forget, we haven’t had the societal expectation for moms to be active throughout motherhood, including pregnancy, for very long.  We were very much judging women who would run in pregnancy, very much judging women who were lifting up a barbell, and now, at least in my circles, that’s pretty normal.

It’s normal in mine, and then seeing it in the media – it’s so inspiring to see the Olympic athletes.  I love it!

Yes!

Who is your favorite role model for the athletic world as far as moms go?

I don’t even know where to begin.  I think one of my favorites is Sophie Power.  She is a UK Ultra athlete.  You might have seen her a number of years ago.  She was running six months postpartum, and she stopped at a rest station to breastfeed in the middle of the race.

Oh, that was amazing!

We had Sophie on The Active Mom Postpartum Podcast and talked to her, and she has since gone on to have two more kids and has become a huge, huge advocate for women’s equity at races, making sure that we have products, making sure that women have lactation support.  And then she’s also been a huge advocate for physiotherapy and talking about her experience working with some great physios over in the UK, like Emma Brockwell.  Again, using her platform to educate others that there are options and that women deserve more.  That, and she can run Ultras like crazy, which I’m hugely jealous of.  So, yeah, Sophie Power, I’m a huge fan girl.

Another one is Annie Thorisdottir, who was a previous three times CrossFit Games athlete and winner.  She had her first child during the pandemic, and she’s been incredibly open.  She’s since had another child, but she’s been incredibly open about navigating that process as an athlete and sharing what she does.  I think any athlete that’s open to sharing her process, because there’s so many people that look up to them, and sharing what they’ve learned and mistakes and all of that – it’s hard to share that in real time, but it’s for the greater good.  So any athlete that’s sharing that process and showing how real and challenging it is, anybody who’s a mom or has been pregnant, you know that this stuff ain’t easy.

Steph Bruce is another one.  She just had her third.  She’s a professional runner for Hoka, and she’s been super open about sharing her process with physio, as well.

The list could go on.  I could do a whole podcast on all the moms that I fangirl over.

We have to have you back for that one!  I love it, and I will need to listen to that Active Mom Postpartum Podcast episode to get even more inspired and share it with the athletes that I work with!

So how can our listeners connect with you, Carrie?

Pretty easy to find me, over on Instagram, where it’s a little happier, @carriepagliano.  And then my practice is in Arlington, Virginia, but I also do telehealth and virtual consults all over the globe.  One of my super powers is finding and collecting resources for other people, and chances are, if you’re looking for a resource in your area, I probably know somebody or know somebody who knows somebody.  It’s the idea of creating a village for moms.  If you think that this is something that you’re looking for, reach out to me.  Let me know if there’s anything that I can do to help guide you towards a resource that might help you get further in your journey with good, vetted evidence informed information.  I’m always happy to do that!

I love it.  Thank you for all the work you’re doing in the women’s health space and for your passion and podcast, all of it.

Thanks for having me!

IMPORTANT LINKS

Carrie Pagliano Physical Therapy

Birth and postpartum support from Gold Coast Doulas

Becoming A Mother course

Buy our book, Supported